Provider Demographics
NPI:1114528973
Name:DAVIS JACKSON MEDICAL ASSIST TEAN LEE
Entity Type:Organization
Organization Name:DAVIS JACKSON MEDICAL ASSIST TEAN LEE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:FLORENSE
Authorized Official - Middle Name:MONIQUE
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:CNA
Authorized Official - Phone:651-595-5960
Mailing Address - Street 1:1321 E. 78TH STREET APT. 114
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1114
Mailing Address - Country:US
Mailing Address - Phone:651-592-5960
Mailing Address - Fax:651-286-2994
Practice Address - Street 1:6449 IPTH DR.
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55725-1130
Practice Address - Country:US
Practice Address - Phone:657-592-5960
Practice Address - Fax:651-286-2994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes372600000XNursing Service Related ProvidersAdult CompanionGroup - Multi-Specialty
No372500000XNursing Service Related ProvidersChore ProviderGroup - Multi-Specialty
No373H00000XNursing Service Related ProvidersDay Training/Habilitation SpecialistGroup - Multi-Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
No376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty